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        <p>调合主要应用于早期，以CDH为主诉就诊。<br>第三节 化学治疗(CDH的三种脱敏方式)<br>有症状时不要急于脱敏，治标不治本。<br>1.化学治疗概述<br>a.化学治疗的本质<br>避免牙本质进一步过敏<br>阻断CDH作用机制<br>化学治疗的本质——脱敏<br>b.特性及使用环境分类<br>家用脱敏剂<br>诊室用脱敏剂<br>c.作用机制分类<br>神经脱敏剂<br>牙本质小管阻塞剂<br>混合制剂<br>2.神经脱敏剂<br>a.钾离子是临床常用的神经脱敏剂<br>b.作用在神经纤维去极化的过程并阻止复极化<br>c.临床常用为硝酸钾和草酸钾制剂<br>35%硝酸钾可立刻缓解91%的CDH<br>含硝酸钾的牙膏有缓解CDH的作用<br>3.牙本质小管阻塞剂<br>草酸类制剂<br>a.临床常用的是草酸盐制剂<br>b.原理:在牙本质小管内壁形成沉淀结晶阻止小管液流动。<br>锶类制剂<br>a.占据牙本质小管改变钠钾通透性<br>b.小管内形成沉淀和结晶阻塞牙本质小管。<br>c.临床常用氯化锶牙膏<br>戊二醛类制剂(格鲁玛)<br>a.含5%戊二醛和35%HEMA<br>b.HEMA携带戊二醛进入牙本质小管与血清白蛋白形成沉淀。<br>c.阻塞或占据牙本质小管阻止小管液流动。<br>4.混合制剂<br>草酸+氢氧化钾<br>5.grippo的五步脱敏法<br>适应症<br>a.无法确定CDH病因并存在症状<br>b.无明显牙体组织缺损<br>c.不是树脂充填适应症(修复空间不足)<br>d.不是牙周覆盖根面手术适应症<br>流程步骤<br>a.2%氯己定和浮石粉清洁牙面，排龈，干燥，5%硝酸钾凝胶10分钟<br>b.48-72h后重复第一步。<br>c.生物腐蚀类(涂戊二醛)应力或磨损类(草酸钾)<br>d.48-72h后重复第三步。<br>e.48-72h后涂布自酸蚀粘接剂或氟保护漆封闭<br>第四节 激光治疗<br>1.概述<br>a.激光治疗cdh是一种创新、微创的有效方法。<br>b.脱敏效果取决于波长，参数和具体设置。<br>c.治疗结果各异不统一有待进一步研究。<br>2.低能激光的应用<br>a.用于临床的应用:主要是软组织和美白等。<br>促进愈合，减轻疼痛，对炎症起生物调节作用b.优点:价格低操作简便;减轻炎症过程;形成反应性牙本质。<br>c.原理:光物理和光化学;光生物学;释放能量作用于组织和细胞。<br>d.建议配合脱敏治疗使用<br>3.高能激光的应用<br>a.临床应用:阻塞牙本质小管，降低牙本质通透性，脱敏。<br>b.优点:快速脱敏。缺点:价格昂贵。注意控制温度和牙髓损害。<br>c.原理<br>使牙本质羟磷灰石融化冷却后形成更大结晶。<br>阻塞牙本质小管。<br>改变牙本质通透性及原有结构，增加抗酸性。<br>第五节 联合治疗方案<br>1.CDH的治疗程序<br>①咬合治疗优先<br>②胃食管反流性疾病的治疗<br>③脱敏治疗<br>2.CDH的联合治疗策略<br>①神经脱敏<br>②物理阻塞<br>3.CDH的激光照射联合治疗步骤<br>第六节 牙齿美白的考量<br>①美白疼痛的机理<br>a.过氧化氢渗入牙体组织内部<br>b.直接激活疼痛感受器<br>c.渗入速度快，术后疼痛明显。<br>②CDH美白考量<br>a.寻找病因解除<br>b.封闭脱敏后美白<br>第四章 NCCL的修复治疗方案<br>第一节 NCCL的粘接修复<br>1.循证医学支持的粘接流程。<br>①术野隔离(橡皮障或棉卷)<br>a.能上障尽量上障<br>b.不能上障则排龈，棉卷隔离。<br>c.术野干燥，清洁，清晰可见。<br>②窝洞预备(是否必须?)<br>a.冠方边缘釉质需预备<br>b.预备45°短斜面<br>c.美塑树脂预备浅凹形(树脂较硬)<br>d.本质界面无需预备<br>③选择合适的粘接系统<br>a.使用传统三步粘接系统(四代)<br>全酸釉质30s本质15s湿粘接<br>b.两步自酸蚀粘接系统(六代)<br>选择性酸蚀釉质(本质新鲜)<br>釉质酸蚀30s本质使用自酸蚀处理一起涂布粘接。<br>c.改良选择性酸蚀(硬化牙本质)<br>釉质酸蚀30s，本质EDTA处理2min，微湿状态自酸处理一起涂布粘接。<br>d.通用型含MDP<br>釉质酸蚀30s，本质EDTA处理2min，微湿状态自酸处理一起涂布粘接。<br>④涂布粘接剂(提高粘接的几种方式)<br>a.用三步全酸、选择性两步自酸系统及通用加压涂布<br>原理:1)使三步全酸的高分子树脂单体向湿润的牙体扩散。2)用三步全酸时加压使胶原纤维网压缩回弹引导粘接剂渗入。3)用二步自酸和通用粘接剂时加压涂布能增强粘接界面耐久性。4)明显减少釉质边缘远期变色现象。5)加压涂布不增加操作时间有利于医生临床操作。<br>⑤粘接剂涂布后的干燥模式<br>含有溶剂的要中等强度吹10s(画√)，不含溶剂的只要轻吹(画叉)。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/015/01.png"><br>干燥时间，原理分析及有效干燥方案<br>时间:10-20s<br>原理:1)粘接层固化时残留溶剂/水损害粘接界面的完整性。2)粘接强度和粘接效果不佳。<br>方案:1)搅动加压延长涂布时间。2)可参考负压吸引器。<br>⑥光固化<br>粘接剂光固化推荐40s。前20s渐增强度，后20s恒定强度。后20s温度高可配合吹气。<br>原理:1)延长固化时间可产生更高的能量密度。2)形成更多的自由基增加聚合。3)产生热量促进溶剂挥发。4)可降低二步自酸和通用粘接系统的降解。<br>固化灯选择考量<br>1)粘接剂中引发剂类型及波长吸收峰值<br>2)溶剂残留会改变粘接剂中引发剂的波长吸收峰值。<br>第二节 NCCL修复的树脂材料的选择<br>1.复合树脂材料的历史发展和演变<br>a.机械强度增加<br>b.可随时固化<br>c.美学效果好<br>d.填料颗粒变小易抛光<br>e.未来的目标:聚合收缩更小的树脂系统<br>2.复合树脂的组成成分<br>a.单体<br>bis-GMA是复合树脂的基础<br>个别添加TEGDMA单体增加反应活性<br>个别树脂是UDMA与bis-GMA的高转化率树脂<br>粘接流体树脂是bis-GMA加入GPDM(磷酸酯)<br>b.填料<br>改善树脂的机械性能和耐磨性<br>降低树脂收缩率<br>常用的有玻璃、石英及其它形式的硅<br>c.硅烷及引发剂<br>在无机填料表面<br>无机填料与有机基质结合<br>改善机械性能控制聚合收缩<br>3.复合树脂的分类形式<br>a.根据粘稠度分类<br>流动树脂——低粘度，高流动，低填料，高收缩。<br>可充填树脂——高粘度，低流动，高填料，低收缩。<br>b.根据填料特点分类<br>填料颗粒平均大小&gt;1μm，大颗粒填料树脂(抛光差)<br>填料颗粒平均大小&lt;1μm，微填料树脂(抛光好，强度差)<br>填料颗粒平均大小0.4μm-1μm，微混合填料树脂(抛光好，强度好)现在的主流。<br>填料颗粒平均大小5nm-75nm，纳米填料树脂或纳米混合(最尖端)<br>4.复合树脂修复NCCL的优势<br>a.不需要打磨过多牙齿<br>b.弹性模量与牙本质相似<br>c.与牙体可粘接<br>d.承受咬合力时与牙本质表现相似<br>5.复合树脂材料的选择<br>a.机械性能<br>b.保存牙体组织<br>c.良好美学<br>d.功能与维护<br>1)混合填料树脂——首选<br>优点<br>美学效果好<br>强度够易于使用<br>缺点<br>收缩应力<br>2)微填料树脂——次选<br>优点<br>美学效果好<br>弹性模量低可以与牙齿一同弯曲<br>降低粘接界面失败率减少脱落<br>缺点<br>耐磨性差<br>3)流体树脂——不选<br>优点<br>操作特性好可注射窝洞。<br>充填步骤简化<br>缺点<br>填料含量低机械性能差<br>聚合收缩大<br>高填料流体(80%)热循环微渗漏大<br>高应力集中区不用<br>4)大块充填树脂——争议大<br>优点<br>一次固化4-6mm节约时间<br>固化深度增加收缩应力小<br>适合高C因素洞型<br>缺点<br>机械性能与传统树脂类似<br>性能不及微混、纳米混合树脂<br>第三节 玻璃离子<br>1.组成成分<br>粉剂:硅铝酸盐<br>液:酒石酸，马来酸，衣康酸等<br>2.与釉质和牙本质的粘接原理<br>聚烯酸羧基与羟磷灰石形成离子键。<br>3.不用在NCCL修复中的原因<br>内聚力差<br>粘接强度差<br>美观性差<br>耐磨性差<br>第四节 NCCL陶瓷修复的材料选择<br>1.陶瓷的特点<br>颜色稳定性好<br>表面光泽好<br>抗磨耗<br>不易聚集菌斑<br>2.陶瓷用于修复NCCL的原因<br>不导电、不导热<br>表面光滑度高可上釉<br>无细胞毒性不水解<br>长期使用无副产物<br>有利于牙周健康<br>3.适应症<br>伴有牙龈退缩的NCCL<br>建议在根面覆盖术前修复<br>牙龈组织可直接与瓷接触<br>4.陶瓷材料的选择<br>精细的二硅酸锂颗粒结构相互锁合阻止裂纹发展。<br>5.NCCL修复技术的分类及优缺点<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/015/02.png"><br>个人总结:CDH的脱敏治疗，主要有神经脱敏剂和牙本质小管阻塞剂两种，配合激光治疗有更好的效果。NCCL的修复材料主要有复合树脂和陶瓷。用得最多的是复合树脂。常选择混合填料树脂，牙体预备釉质边缘预备短斜面，本质不预备。若使用美塑树脂预备为浅凹形。粘接系统可使用四代，六代或八代，如果是硬化牙本质可使用EDTA处理2分钟。涂布粘接剂需要加压涂布。如果涂布成分含水或溶剂需要用中等气流吹，若无则轻吹即可。涂布粘接系统后光固化40s。伴牙龈退缩的NCCL可使用瓷修复，先修复后再行根面覆盖术。</p>
<p>我发文章的四个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的博客园博客地址： <a target="_blank" rel="noopener" href="https://www.cnblogs.com/zwdnet/">https://www.cnblogs.com/zwdnet/</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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